Chapter 3 -- Diagnosis and Assessment

I. Diagnostic Process

A. Client's Reported and Observable Symptoms
B. Reports by others (parents, teacher, therapist)
C. Previous Records (written reports, grades)
D. Test Results (personality and intellectual)
E. Diagnostic Criteria and Differential Diagnosis
F. Case Formulation (biopsychosocial causes, patterns, treatment response)
G. Cultural Formulation (beliefs, identity, support, and treatment preferences)

II. 12 Month Prevalence of Common Diagnoses

A. U.S. has highest rates in the world
1. 26.4% any diagnosis
2. 18.2% Anxiety Disorders
3. 9.6% Mood Disorders
4. 3.8% Substance Disorders
B. France is next highest in the world
1. 18.4% any diagnosis
2. 12.0% Anxiety Disorders
3. 8.5% Mood Disorders
4. 0.7 Substance Disorders

III. Criteria for Good Tests

A. Reliability (consistency of test scores)
1. Test-retest (same scores on different days)
2. Internal consistency (how much items correlate with each other)
3. Inter-rater (2 or more raters get the same answers)
B. Validity (measures what it intends to measure)
1. Content (reflects the body of information)
2. Concurrent (correlates with other similar measures)
3. Predictive (test scores relate to a benchmark in the future)
C. Standardization (same testing conditions)

IV. Diagnostic and Statistical Manual of Mental Disorders (DSM)

A. 1952 DSM, 86 pages on emotional reactions, 106 disorders from psychoanalytic theory
B. 1968 DSM-II based on International Classification of Diseases (ICD) had 182 disorders
C. 1980 DSM-III was more reliable and less theoretical, 265 disorders
D. 1994 DSM-IV had 292 disorders
E. 2013 DSM-5 has approximately 400 disorders

V. DSM-5 Assumptions

A. Medical Model where disorders are viewed as diseases
B. Non-theoretical Orientation is descriptive and not explanatory
C. Categorical Approach separates specific diagnoses from normal functioning and other disorders
D. Dimensional Approach assesses severity of symptoms

VI. Five Axes of DSM-IV-TR

A. Axis I: Clinical Disorders
B. Axis II: Personality Disorders and Mental Retardation
C. Axis III: General Medical Conditions
D. Axis IV: Psychosocial and Environmental Problems (Educational, Occupational)
E. Axis V: Global Assessment of Functioning (1 suicidal to 100 superior)

VII. One Axis of DSM-V

A. Axis I:  Clinical Syndromes (descriptions of symptoms, rate severity on a continuum such as individual symptoms from "not at all" to "nearly every day")
B. Other Descriptors: Psychosocial and Environmental Problems (Educational, Occupational)

Example Diagnosis in DSM-IV

Axis I: 296.43 Bipolar I Disorder, most recent episode manic, severe without psychotic features
Axis II: Diagnosis deferred.
Axis III: None
Axis IV: Problems with primary support group (divorce)
Axis V: Current Global Assessment of Functioning (GAF): 43. Highest GAF in past year: 80

Example Diagnosis in DSM-5

Bipolar I Disorder, most recent episode manic
High Blood Pressure

VIII. Criticisms of DSM

A. Too Many Diagnoses that label more and more people
B. Comorbidity – presence of other diagnoses
C. Reliability – lower in everyday use if criteria not followed precisely, interrater reliability lowest among anxiety disorders
D. Validity – may not organize clients’ information well, may not predict recovery well
E. Danger of stigma

IX. Interview Formats

A. Unstructured Clinical Interviews (Attend to client’s concerns)
B. Mental Status Examination (Behavior, Appearance, Orientation, Speech and Thought, Mood, Perceptions, Insight, Motivation, Cognitive Functioning)
C. Structured Diagnostic Interviews (Use DSM criteria in questions; DIS, SCID)

X. Psychological Testing

A. Primary types of Tests
1. Personality (Measure characteristic ways of thinking, feeling, and behaving)
2. Intellectual (Measures cognitive ability)
B. Assumptions
1. Compare an individual with the averages for a large group
2. Tests can be reliable and valid

XI. Personality Testing

A. Objective (same items and response choices for everyone)
1. MMPI-2 (567 items) measures clinical symptoms, personality characteristics, and validity of responses
B. Projective (project meaning to ambiguous stimuli)
1. Rorschach Inkblot Test (what do the blots look like?)
2. Thematic Apperception Test (TAT) (tell a story about the picture)

XII. Intelligence Testing

A. Used in diagnosis and assesses strengths and weaknesses (intellectual developmental disorder and learning disorders)
B. Identifies intellectually gifted children
C. Highly correlated with educational and occupational success
D. 4 indexes: Verbal Comprehension, Working Memory, Perceptual Organization, and Processing Speed

XIII. Behavioral Assessment

A. Self-report checklists of a variety of behaviors
B. Self-monitoring a specific behavior with the date, time, location, duration, quantity, quality, antecedents, and consequences
C. Behavioral observations of others (video cameras, security and law enforcement)

XIV. Neurobiological Assessment

A. Brain Imaging
1. CT and MRI scans reveal brain structure
2. PET and fMRI reveal structure and function
B. Neurotransmitter assessment
C. Neuropsychological assessment (memory, motor speed, spatial ability, and speech)
D. Psychophysiological assessment (EEG for electrical activity in the central nervous system, skin conductance)

XV. Cultural Considerations

A. Beware of cultural bias
B. Make more effort to develop rapport and explain the purposes of the assessment
C. Use structured assessment to reduce bias
D. Develop translations of tests in other languages, assess reliability and validity